Provider Demographics
NPI:1548509730
Name:OSAGIE, EGHOSA O (R-PAC)
Entity type:Individual
Prefix:MR
First Name:EGHOSA
Middle Name:O
Last Name:OSAGIE
Suffix:
Gender:M
Credentials:R-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 FOSTER AVE
Mailing Address - Street 2:APT 5F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-6409
Mailing Address - Country:US
Mailing Address - Phone:347-261-6849
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:718-883-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016310-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant